Using commercial knowledge bases for clinical decision support: opportunities, hurdles, and recommendations.
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Commerce↗
Biomedical subjects
Thomas C Bailey
Publications and source records attributed to Thomas C Bailey.
Inappropriate antibiotic use in a tertiary care center in Thailand: an incidence study and review of experience in Thailand.
The incidence and patterns of and factors associated with inappropriate antibiotic use were studied in a tertiary care center in Thailand. The incidence of inappropriate antibiotic use was 25%. Admission to the surgical department (adjusted odds ratio, 2.0; P=.02) and to the obstetrics and gynecology department (adjusted odds ratio, 2.0; P=.03) were associated with inappropriate antibiotic use, whereas consultation with an infectious diseases specialist was protective against inappropriate antibiotic use (adjusted odds ratio, 0.15; P=.01).
Adolescent↗
Effectiveness of education and an antibiotic-control program in a tertiary care hospital in Thailand.
BACKGROUND: We conducted a study to evaluate the impact of education and an antibiotic-control program on antibiotic-prescribing practices, antibiotic consumption, antimicrobial resistance, and cost of antibiotics in a tertiary care hospital in Thailand. METHODS: A study of the year before and the year after the intervention was performed. Inpatient antibiotic prescriptions were prospectively observed. Demographic characteristics, hospital unit, indication for antibiotic prescription, appropriateness of antibiotic use, reasons for inappropriate antibiotic use, antibiotic consumption (i.e., the rate of antibiotic use), bacterial resistance, and antibiotic cost data were collected. Interventions included education, introduction of an antibiogram, use of antibiotic prescription forms, and prescribing controls. RESULTS: After the intervention, there was a 24% reduction in the rate of antibiotic prescription (640 vs. 400 prescriptions/1000 admissions; P<.001). The incidence of inappropriate antibiotic use was significantly reduced (42% vs. 20%; P<.001). A sustained reduction in antibiotic use was observed (R2=0.692; P<.001). Rates of use of third-generation cephalosporins (31 vs. 18 defined daily doses [DDDs]/1000 patient-days; P<.001) and glycopeptides (3.2 vs. 2.4 DDDs/1000 patient-days; P=.002) were significantly reduced. Rates of use of cefazolin (3.5 vs. 8.2 DDDs/1000 patient-days; P<.001) and fluoroquinolones (0.68 vs. 1.15 DDDs/1000 patient-days; P<.001) increased. There were no significant changes for other antibiotic classes. Significant reductions in the incidence of infections due to methicillin-resistant Staphylococcus aureus (48% vs. 33.5%; P<.001), extended-spectrum beta -lactamase-producing Escherichia coli (33% vs. 21%; P<.001), extended-spectrum beta -lactamase-producing Klebsiella pneumoniae (30% vs. 20%; P<.001), and third-generation cephalosporin-resistant Acinetobacter baumanii (27% vs. 19%; P<.001) were also observed. Total costs saving were USD 32,231 during the study period. CONCLUSIONS: Education and an antibiotic-control program constituted an effective and cost-saving strategy to optimize antibiotic use in a tertiary care center in Thailand.
Anti-Bacterial Agents↗
Dual infection with Mycobacterium tuberculosis and Pneumocystis jiroveci Lymphadenitis in a Patient with HIV infection: case report and review of the literature.
We report a case of dual Mycobacterium tuberculosis (TB) and Pneumocystis jiroveci (carinii) (PCP) lymphadenitis in a patient with HIV who had been receiving trimethoprim-sulfamethoxazole (TMP-SMX) as systemic prophylaxis for PCP. This patient was successfully treated with antituberculosis medications and TMP-SMX. Our review of the literature identified this as the first reported case of dual TB and PCP lymphadenitis in an HIV-infected host and highlights the potential limitations of TMP-SMX prophylaxis.
Adult↗
Implementing a commercial rule base as a medication order safety net.
A commercial rule base (Cerner Multum) was used to identify medication orders exceeding recommended dosage limits at five hospitals within BJC HealthCare, an integrated health care system. During initial testing, clinical pharmacists determined that there was an excessive number of nuisance and clinically insignificant alerts, with an overall alert rate of 9.2%. A method for customizing the commercial rule base was implemented to increase rule specificity for problematic rules. The system was subsequently deployed at two facilities and achieved alert rates of less than 1%. Pharmacists screened these alerts and contacted ordering physicians in 21% of cases. Physicians made therapeutic changes in response to 38% of alerts presented to them. By applying simple techniques to customize rules, commercial rule bases can be used to rapidly deploy a safety net to screen drug orders for excessive dosages, while preserving the rule architecture for later implementations of more finely tuned clinical decision support.
Clinical Pharmacy Information Systems↗
Strategies for reducing nuisance alerts in a dose checking application.
Commercial rule bases can be implemented to identify medication orders that fall outside recommended dosage ranges, but they are likely to produce an excessive number of nuisance and clinically insignificant alerts. Strategies for customizing commercial dosing rules can be implemented to minimize this problem. This paper describes specific strategies implemented in a dose checking application necessary for achieving a clinically acceptable alert rate.
Clinical Pharmacy Information Systems↗
Redesigning an infection control application to support an enterprise model.
As the demands on hospital infection control teams increase, it becomes less efficient for them to use paper-based surveillance methods. The existing electronic infection control surveillance system at our largest facility was not designed to support a multi-hospital model. Our goal was to redesign the application using generic, open source technologies, and make it flexible enough to support the infection control surveillance needs of the entire enterprise.
Cross Infection↗
Automatic detection of spironolactone - related adverse drug events.
Due to increasing reports of spironolactone associated life-threatening hyperkalemia, we implemented a rule in our automated event detection system to monitor serum potassium results in patients receiving spironolactone. In 2004, 419 (10.49%) of 3995 admissions at 3 BJC HealthCare hospitals were identified as having hyperkalemia while on spironolactone. For a 9-month period in one facility, 33 of 52 automatically detected potential ADEs had been validated by pharmacists through manual chart review to have spironolactone as a contributing factor (PPV=63.5%).
Adverse Drug Reaction Reporting Systems↗
Construction and validation of an automated model for the early identification of patients hospitalized for heart failure.
In order to institute early hospital-wide interventions, we constructed a reliable automated model for identifying newly admitted patients with congestive heart failure using electronically captured administrative and clinical data.
Adult↗
Using outpatient prescription claims to evaluate medication adherence in an acute myocardial infarction population.
We have previously shown that using computerized alerts and academic detailing results in significant improvement in physician adherence to secondary prevention guidelines for acute myocardial infarction. However, information about patient medication adherence after hospital discharge was not previously available. Using electronic outpatient prescription claims data, medication adherence for a coronary artery disease population is described.
Ambulatory Care↗
Physicians' knowledge and attitudes about coronary heart disease prevention guidelines and technology assisted interventions.
BJC Healthcare is conducting a randomized controlled study to evaluate the impact of a technology-assisted pharmacist intervention on physicians' adherence to national coronary heart disease (CHD) prevention guidelines. We surveyed physicians to assess their knowledge of the guidelines and attitudes toward pharmacist-mediated interventions.
Attitude of Health Personnel↗
Intervention to improve dyslipidemia screening in hospitalized diabetics.
Using an automated method to prospectively identify diabetic patients, we measured the impact of an administrative policy to perform LDL-cholesterol (LDL-c) testing on all diabetics not having the test performed within a specified time period. Automatic testing resulted in significant increases in LDL-c testing rate, and identified a greater proportion of patients who were candidates for statins. Further interventions are needed to increase prescriptions for lipid-lowering therapy.
Blood Chemical Analysis↗
Customizing a commercial rule base for detecting drug-drug interactions.
We developed and implemented an adverse drug event system (PharmADE) that detects potentially dangerous drug combinations using a commercial rule base. While commercial rule bases can be useful for rapid deployment of a safety net to screen for drug-drug interactions, they sometimes do not provide the desired rule sensitivity. We implemented methods for enhancing commercial drug-drug interaction rules while preserving the original rule base architecture for easy and low cost maintenance.
Adverse Drug Reaction Reporting Systems↗
Concordance between medication histories and outpatient electronic prescription claims in patients hospitalized with heart failure.
Using an electronic prescription claims database and electronic hospital records, we retrospectively compared outpatient heart failure (HF) prescriptions dispensed with reported use obtained during medication histories taken at hospital admission. We found significant disagreement between each source for all but one HF medication class.
Clinical Pharmacy Information Systems↗
The association of cytomegalovirus sero-pairing with outcomes and costs following cadaveric renal transplantation prior to the introduction of oral ganciclovir CMV prophylaxis.
Cytomegalovirus (CMV) is an important cause of morbidity, mortality and cost in cadaveric renal transplantation. This study was designed to document the clinical and economic outcomes associated with donor and recipient CMV sero-pairing. Data were drawn from the United States Renal Data System (USRDS) on 17 001 cadaveric renal transplant recipients transplanted between 1995 and 1997 with recorded donor and recipient CMV sero-status. In multivariate analysis, CMV-seropositive recipients were associated with a significantly higher incidence of delayed graft function, a lower incidence of graft loss, and lower costs than CMV-seronegative recipients. CMV-seropositive compared to seronegative donors were associated with significantly higher incidence of CMV disease, graft loss, and higher costs when transplanted into CMV-seronegative recipients. However, CMV-seronegative donors into seropositive recipients had no significant association with outcome beyond a higher incidence of CMV disease compared to CMV-seronegative donor and recipient pairs. The outcomes associated with CMV-seropositive donors and seronegative recipients call for tailored management strategies which may include avoidance of such mismatching, antiviral therapy, immunization, or modified immunosuppression.
Administration, Oral↗
Monitoring pharmacy expert system performance using statistical process control methodology.
Automated expert systems provide a reliable and effective way to improve patient safety in a hospital environment. Their ability to analyze large amounts of data without fatigue is a decided advantage over clinicians who perform the same tasks. As dependence on expert systems increase and the systems become more complex, it is important to closely monitor their performance. Failure to generate alerts can jeopardize the health and safety of patients, while generating excessive false positive alerts can lead to valid alerts being dismissed as noise. In this study, statistical process control charts were used to monitor an expert system, and the strengths and weaknesses of this technology are presented.
Clinical Pharmacy Information Systems↗
Validation of automated event triggers using laboratory values related to two problem-prone drugs.
We used computerized alerts to identify patients with laboratory values that could be related to medication errors associated with digoxin and warfarin. Over a six-week period at two inpatient facilities, we generated 62 laboratory-based alerts for warfarin, and 66 for digoxin. The positive predictive value for these alerts representing a preventable event was 71% and 57% for warfarin and digoxin, respectively.
Anticoagulants↗
Implementing a commercial rule base as a medication order safety net.
A commercial rule base was used to identify drug orders exceeding standard dosage limits at a university hospital. Initially, there were substantial numbers of clinically insignificant alerts. A method for altering the commercial rule base will be implemented to increase rule specificity for problematic drugs. With minor modifications, commercial rule bases can be used to rapidly create a safety net that screens drug orders for excessive dosages, while preserving the rule architecture for more finely tuned clinical decision support.
Drug Therapy, Computer-Assisted↗